Provider Demographics
NPI:1902850779
Name:HAGGE, REGG A (MD)
Entity Type:Individual
Prefix:
First Name:REGG
Middle Name:A
Last Name:HAGGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 ONYX ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3214
Mailing Address - Country:US
Mailing Address - Phone:307-877-4496
Mailing Address - Fax:307-877-9769
Practice Address - Street 1:711 ONYX ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3214
Practice Address - Country:US
Practice Address - Phone:307-877-4496
Practice Address - Fax:307-877-9769
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11278A207Q00000X
SD5642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5607445Medicaid
SD5607446Medicaid
SD433414Medicare Oscar/Certification
SDS109766Medicare PIN
SDS103567Medicare PIN
H29106Medicare UPIN
SDH29106Medicare UPIN
SD5607445Medicaid